Environments of Exclusion

With the onset of deinstitutionalization in the 1960s, many people with mental illness left large in-patient psychiatric hospitals and began filtering into community and family-based care settings.

The residential care facilities that existed at the time were generally located in downtown urban areas, close to the hospitals that were formerly home and that continued to provide outpatient services. In the southwestern Ontario city of Hamilton, such housing is still largely clustered in the downtown core around two large hospital facilities.

“There are still at least 10 homes in the downtown core,” says Margaret Foley, housing director for Canadian Mental Health Association, Hamilton Branch, “and another large pocket in the city’s east end.” But now, she says, many CMHA clients are requesting to move elsewhere, especially the “mountain” area of Hamilton, the southern half of the city located atop the Niagara escarpment. She explains that some clients, particularly those with serious addiction issues, want to get away from the downtown core because they would find it easier to avoid unsafe places and situations.

But personal choice is often limited by the built environment — the way a city and surrounding area is laid out. Although some people have moved away to smaller centres on the periphery of Hamilton, such as Mount Hope or Waterdown, says Foley, these can be much more challenging environments, often lacking accessible transportation, affordable housing, community centres and social services. So she tries to encourage clients to stay more central and locate in areas close to transit and amenities.

The range of housing choices for people with mental illness is also significantly affected by stigma and discrimination, which remain major barriers. “One difficulty is that landlords are sometimes reluctant to offer housing to our clients. They anticipate difficulties by virtue of their association with our organization,” says Foley. “Hamilton has fairly high vacancy rates, so there are a lot of units, but the landlords often have reservations of renting to people who need ‘help’ to find a place.” Although CMHA staff do not disclose any personal details about their clients, landlords will still express concerns.

According to Dr. Robert Wilton, the “systemic barriers to inclusive living for persons with mental illness are very similar to those issues faced 30 years ago.” Wilton is an associate professor of geography at McMaster University in Hamilton with a research interest in disability, exclusion and the social geography of cities.

“Many persons with mental illness are disproportionately living in poverty, have employment problems and are faced with stigmatization on a daily basis,” observes Dr. Wilton. Poverty is an ongoing threat to people’s quality of life. As well, research continues to point to a shortage of appropriate housing for people living with mental illness. Those in lodging homes rely on a monthly Personal Needs Allowance of $119, says Wilton, which leaves them with few resources for even basic items such as toiletries and clothes. For people who move out of lodging homes, high rents eat away at monthly Ontario Disability Support Program (ODSP) income.

Dr. Wilton says that issues of affordability and access to mental health care have created what he and other researchers call service ghettos: “the concentration of certain people in specific areas because of the access to high levels of services.” The creation of service ghettos, he says, can lead to a self-reinforcing cycle whereby persons with serious mental illness are only found in specific locations.

Personal choice is often limited by the built environment — the way a city and surrounding area is laid out.”

Exclusionary elements in many communities, such as discriminatory zoning bylaws, community opposition, large distances and inaccessible transportation, are a big part of how service ghettos are created in the first place. When residents resist the creation of new supportive housing in their neighbourhood, by complaining about decreased property values or reciting the myth that persons with mental illness are dangerous, they influence municipal planning to keep people out. This results in the centralized location of services and housing in the downtown core or around psychiatric hospitals, according to Dr. Wilton, so “the groups of people who have significant mental illness have to gravitate from other areas of the city to access health services.”

Yet if a range of accessible resources were available in outlying areas, people’s choices of where to live would be much broader. Dr. Wilton believes that the creation of multiple service hubs would help the situation and would “fight against the tendency to concentrate certain people in certain areas.” Community-based service hubs would provide information, referrals and an integrated array of services and supports, such as health and child care, food banks, skills training and educational opportunities. Distributed across neighbourhoods and jurisdictions, service hubs would foster positive relationships between persons with mental illness and other members of the community. An integrated municipal planning process that considered the physical location of community resources, therefore, could prevent some of the systemic exclusion and isolation of persons with mental illness.

Looking to the future, the implementation of service hubs might provide a long-term solution to the ghettoization of community resources and people. In the meantime, service providers are finding creative ways to maximize client choice and improve housing conditions despite existing barriers.

Since 1999, the Ontario government-funded HOMES program run by the Good Shepherd Centre in Hamilton has provided housing for people with serious mental illness who are homeless or at risk of homelessness. With about 250 units that provide housing and related supports, the cornerstone of the program is its use of mobile support services. While four buildings provide more traditional on-site supportive housing arrangements, the program also places clients in 150 privately owned apartment units scattered throughout 20 different buildings. Tenants meet weekly with staff from a mobile support team, either at home or in the community, receiving support where they live.

One of the most important considerations is client choice, says Heidi Billyard, director of tenant and housing services for Good Shepherd. When the program first started, the majority of the units were in the downtown area, says Billyard, but as it grew, people started requesting to relocate to other areas of the city. “People would say, ‘I’d really like to live in the east end’ or ‘on the mountain.'” Billyard also considers other things when looking for housing for a client, such as access to public transit, and amenities like grocery stores, pharmacies and community centres.

Supporting client choice is also important for Margaret Foley. The housing units managed by CMHA Hamilton Branch are generally spread out across the city, and people’s preferences are accommodated as much as possible. But Foley and Billyard agree that many of their clients remain clustered in certain areas of the city, often because they don’t want to be cut off from existing support systems and social networks, and because many community resources, such as the library, drop-in centres and food banks, are within walking distance. Individual choice is restricted by where things are located in the city.

While programs like those offered by Good Shepherd and CMHA can help improve housing conditions and promote greater choice, Billyard and Foley agree that their resources are already fully tapped. So, many people living with mental illness in Hamilton and the surrounding area must rely on lodging homes and other non-profit or for-profit care residences that may not provide the same kind of flexible supports or access to community resources.

Over the past few years things have improved, says Marilyn Jewell, executive director of CMHA Hamilton, because of programs such as the Mental Health Homelessness Initiative. This Ministry of Health and Long-Term Care program provides subsidies to cover rent for clients of local agencies that provide community support services. Hopefully, such initiatives, along with the work of local advocacy organizations and researchers like Dr. Wilton, will continue to draw attention to the issues and provide solutions that promote fairly distributed resources, greater choice and better living conditions in all communities.

Michael Slechta is a graduate of York University’s master’s program in Critical Disability Studies.